Guest Columnist

Let’s Talk About Sex

By ATUL GAWANDE

Published: May 19, 2007

One statistic seems to me to give the lie to all the rhetoric about abortion, and it’s this: one in three women under the age of 45 have an abortion during their lifetime. One in three. All politicians — Democrat and Republican — say they want to make abortion at least rare (as Giuliani did in Wednesday’s debate). On, this they could reach agreement. But it’s clear they haven’t been serious; the U.S. has 1.3 million abortions a year.

Reducing unintended pregnancy is the key — half of pregnancies are unintended, and 4 in 10 of them end in abortion. For a while now, we’ve had solid evidence about how to effectively do this. But it requires getting specific about two subjects that are perilous in politics: sex and contraception. That, politicians won’t do. So let me try to help with four facts everyone needs to know.

Fact one is that, with children, parents do matter. Reviews of multiple studies have shown that parents who maintain a close relationship with their teenage children, monitor them carefully, and send a certain message about sex actually do reduce unintended pregnancies. That message, when most effective, is neither permissive about sex nor focused only on abstinence, but instead combines two components. First, it emphasizes throughout high school that teenagers should wait until they’re older to have sex (because the majority regret not waiting; because having a child as a child wrecks their lives); and second, it makes it clear that when they ultimately have sex, they should always use protection.

More children are, in fact, getting this message. Pregnancies at age 15 to 17 are down 35 percent since 1995, according to federal data; one-fourth of the drop is from delaying sex, and three-fourths is from increased use of contraceptives. Today, just 7 percent of abortions occur in minors.

Fact two follows from this: Abortion is mainly an adult problem. Forty-five percent of abortions occur in adults ages 18 to 24; 48 percent occur after age 25. Most are in women who have already had a child. The kids are all right. We are the issue.

Fact three is that our biggest problem is not using contraception properly: 92 percent of abortions occur in women who said they used birth control. Six in 10 used contraception the month they got pregnant. The others reported that they had used birth control previously but, for one reason or another, not that month. (Many, for example, say they didn’t expect to have sex.) The trouble appears to be blindness to how easy it is to get pregnant and what it takes to make birth control really work.

Oral contraceptive pills, for example, are nearly 100 percent effective when used consistently. But in the real world, they fail 8 percent of the time — that is, 8 in 100 women on the pill get pregnant in a year. The lower dose hormone formulations used nowadays have fewer side effects, but missing a dose by even six hours puts a woman at serious risk. (One should add condoms for that whole month, experts say.) Miss two days and one is effectively not on birth control at all. Anyone prone to missing really needs to consider switching methods.

Birth control requires constancy, and most people overestimate how constant they can be. Fifteen percent of women who rely only on condoms get pregnant in a year, largely from inconsistency in using them. Withdrawal is even more dicey — it has a 25 percent failure rate.

The most effective methods are long-lasting: I.U.D.’s are safe and nearly 100 percent effective in actual practice. So is Implanon (the under-the-skin implant which replaced Norplant) and surgical contraception. But no method is perfect. Each has downsides — costs, risks, side effects. Every woman must weigh them. A few good Web sites have the details. WebMD is one, for example. But this is where you come to the last fact.

Fact four: you have to educate yourself. The details matter. An effective national campaign would provide the details — on television, on billboards — and actively use what evidence shows works best to cut our massive rate of unwanted pregnancies. But politics precludes this. There’s not going to be such a campaign anytime soon.

Nonetheless, there’s no reason you have to join the one in three — or as a male, contribute to it. You just have to understand: the effort is strictly Do-It-Yourself.

Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston and a New Yorker staff writer, is the author of the new book “Better.” He is a guest columnist this month.

A version of this op-ed appeared in print on May 19, 2007, on page A13 of the New York edition with the headline: Let’s Talk About Sex.